Common Medical Problems in Pregnancy Priscilla E. Pemu, MD, MS, FACP

Common Medical Problems in
Pregnancy
Priscilla E. Pemu, MD, MS, FACP
ACP Georgia Chapter Scientific Meeting
October 5th 2013
Objectives
• At the end of this talk, you will be able to
– Act on evidence-based recommendations for
evaluation and management of common medical
problems in pregnancy
– Confidently prescribe needed medications in
pregnancy
Medical Disorders
•
•
•
•
•
•
•
•
•
•
•
•
•
Asthma
Cystic fibrosis
Hypertension/PIH/PET
Arrthymias
Valvular disease
Cardiomyopathy
Cyanotic heart disease
VSD/ASD
Pulmonary hypertension
Epilepsy
Multiple sclerosis
Intracranial hypertension
Benign cranial tumours eg pit
adenomas
• Obstetric Cholestasis
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Acute Fatty Liver of Pregnancy
IBS
Crohns/Ulceative colitis
Thrombophilias
VTE
Antiphospholipid syndrome
SLE
Rheumatoid arthritis
Sickle cell
disease/thalassaemias
Anaemia
Diabetes
Hypo/hyperthyroidism
Adrenal disease
Cancer
Pregnancy rates
in women over
40 increased 65%
between 19902008
--Ventura SJ et al; 3
National Vital Statistics
Reports,Vol.60,No.7,June
20,2012
Pregnancy and chronic disease
– Pregnancy likely to unmask occult chronic disease
•
•
•
•
•
Glucose intolerance
Renal dysfunction
Hypercoaguable states
Valvular heart disease
Cerebral aneurysm
– Pregnancy as a “stress test for life”
Kaaja and Greer, JAMA 2006
Postpartum effects
• Increased rates of postpartum chronic disease
– Women with GDM have up to 75% likelihood of
developing Type II DM in subsequent five years
– Women with preeclampsia more likely to develop
CAD and stroke later in life
• Higher rates of hypertension, insulin resistance,
dyslipidemia and inflammatory markers
• Primary prevention could play an important role
O'Sullivan, J, Diabetes 1991;
JAMA 1982; Kaaja, JAMA 2005
Approach to Medical Illness in Pregnancy
• Great need for primary providers to
understand medical illness in pregnancy
– Management of medical illness including
appropriate contraception
– Preconception counseling and patient education
– Collaboration with subspecialists, MFM’s
Approach to Medical Illness in Pregnancy
• The tools you need:
– An understanding of the physiologic changes of
pregnancy and how they affect disease
– A basic knowledge of pregnancy specific illnesses
– A strategy for evaluating drug safety in pregnancy
ASTHMA
• Commonest chronic medical illness to complicate
pregnancy
• Up to 3-8%* of women of childbearing age
• Often undiagnosed or undertreated
– A significant increase in complications of pregnancy in
asthmatic women.
– The largest study to date shows a 15 to 20 percent
increased risk of perinatal mortality, preeclampsia,
preterm delivery, or low birth weight infants
compared to non-asthmatic women
– Patients with more severe asthma have a 30 to 100
percent increased risk#
*Kwon HL, et al. Ann Epidemiol. 2003;13(5):317 # Kallen, B, et al. Eur J Epidem 2000; 16:167.
I am wheezing more often
• A 23-year-old non-smoking woman (gravida 1,
para 0) referred to you at 11 weeks' gestation
with an 8-year history of asthma, which has
worsened over the past year.
• She reports symptoms requiring albuterol two or
three times per day and interfering with sleep
every night.
• Her forced expiratory volume in 1 second is 65%
of the predicted value; it increases to 88% after
administration of albuterol. How should her case
be managed?
Answer?
A.
B.
C.
D.
E.
Continue the current regimen
Add Budesonide
Add theophylline
Add salmeterol
Add inhaled cromolyn
Respiratory Changes in Pregnancy
• ↑O2 demand-20%
•
increased consumption
•
• Tidal volume increases
•
• (and with small ↑ in
respiratory rate= large
increase on ventilation-4050% ↑in minute
ventilation)
•
• Inspiratory capacity
increases
Residual volume decreases
Expiratory reserve decreases
Marked reduction in functional
residual capacity
– Diaphragmatic elevation
– Increase in subcostal angle and
transverse thoracic diameter
FEV1 and PEFR are
unchanged
Respiratory Changes
• Progesterone effect probably underlies changes in
ventilation and reduction in CO2
• Directly on respiratory centre
• Increases carbonic anhydrase in maternal RBC
– Increased breakdown of CO2 and excretion of HCO3 through maternal
kidneys
• Functional changes facilitate airflow along bronchial tree
• Women with chronic respiratory disease tend to deteriorate
less in pregnancy
• Peak expiratory flow and FEV1 can still be valid in pregnant
asthmatics
• Shortness of breath is common symptom in pregnancy
• Individual variations in chemoreceptors
• Physiological increase in proportion of blood shunted away
from functioning alveoli
Management
• Emphasis on prevention rather than
treatment
• Treatment in pregnancy is no different to nonpregnant women
– Optimise control prior to pregnancy
– Achieve control asap in new diagnosis
– Use of B2 agonist +/- inhaled corticosteroids
mainstay
Medication Issues
• B2 agonists
– Safe in pregnancy
– Serevent experience growing and ALSO appears safe
• No adverse fetal effects reported with the use of
the following inhaled drugs
–
–
–
–
Disodium chromoglycate
Nedocromil
Anticholinergics (ipratropium)
Inhaled cortocosteroids
Medication Issues
• Steroids
– Inhaled:
• minimal absorption
• No evidence fetal malformations or adverse fetal effects
– Oral
• Should not be withheld in acute attacks
• No strong evidence of fetal malformations, miscarriage,
stillbirth or neonatal death
• Will worsen glycaemic control in diabetics or may increase
risks GDM with long-term use
• Long-term high dose steroids ↑risk premature ROM
Wendel PJ et al; Am J Obstet Gynecol. 1996 Jul;175(1):150-4.
Acute Asthma Attack
• Manage as non-pregnant
– IV rehydration
– O2
– B2 agonists as O2 nebuliser (may be repeated)
– CXR if suspicion pneuthorax/pneumonia or failure
to improve
– Give steroids JUST AS IF pt was not pregnant!
(often inappropriately withheld)
– If not improving, may need IV steroids or inhaled
B2 agonists +/- Magnesium sulfate
I have seizures and want to get
pregnant
• A 25-year-old woman with epilepsy comes to the office
seeking advice about pregnancy.
• She first developed seizures after sustaining a head
injury in a motor vehicle collision at age 16 years.
• MRIs obtained since then have shown an area of
encephalomalacia in the right temporal lobe. Her
seizures were initially refractory to carbamazepine and
valproic acid monotherapy. Carbamazepine was
stopped, and lamotrigine was added to the valproic
acid 1 year ago. She has not had any seizures since that
time.
Answer?
Which of the following is the most appropriate
management?
A. Advise the patient not to become pregnant
B. Continue the valproic acid and lamotrigine
C. Discontinue the valproic acid and continue the
lamotrigine
D. Discontinue the valproic acid and lamotrigine
E. Substitute phenobarbital for her current
medications
EPILEPSY
• About 0.5% women of
childbearing age
• Most diagnosed (known)
prior to pregnancy
• All seizure types may be
affected by pregnancy
• Associated with risks
maternal death due to
aspiration and SUDEP
Effect of Pregnancy on Epilepsy
• 25-30% ↑seizure frequency
• 54% no change
• If seizure free unlikely to have seizures UNLESS
stops medications
• Poorly-controlled (>1/month) likely to
deteriorate in pregnancy
• Risk of seizures highest in peripartum period
Reasons for Deterioration of Control
• Pregnancy
• Poor compliance (Fears of teratogenesis)
• Decreased drug levels due to nausea and
vomiting
• Decreased drug levels due to ↑volume of
distribution and ↑drug clearance
• Lack of sleep towards term and during labour
• Lack of absorption of drugs during labour
• Hyperventilation during labour
Effects of Epilepsy on Pregnancy
• Fetus is relatively resistant to short-term hypoxia
(during seizures)
• No evidence adverse effects
• No increased risks of miscarriage or obstetric
complications (IUGR, PTL, PET etc)
• Status Epilepticus <1% pregnancies BUT dangerous for
mum and baby-TREAT VIGOROUSLY!
• Major risk is teratogenicity of drugs
• Even women on no Rx have ↑risk malformations (4% vs 3% in
general population)
• Risk of child developing epilepsy
•
•
•
•
5% if either parent has epilepsy
15-20% if both
10% if affected sibling and <2 parents affected
9-12% if parent has idiopathic generalised-only 3% if partial
seizures
Teratogenic Risks of Anticonvulsants
• ALL are teratogenic-newer drugs thought to be
safe but now shown to have risks associated with
use
• Major malformations are:
– Neural tube defects (esp valproate 1-2%) and carbamazepine
(0.5-1%)
– Orofacial clefts (especially phenytion)
– Cardiac defects (esp phenytion and valproate)
• Minor malformations (fetal anticonvulsant
syndrome)
– Dysmorphic features (V-shaped eyebrows, lowset ears, broad
nasal bridge, irregular teeth)
– Hypertelorism
– Hypoplastic nails and distal digits
Teratogenic Risks of Anticonvulsants
• Little difference in risk levels between drugs
• Risk for any one drug is 6-7% (2-3x↑)
• Risk increases with number of drugs
(polypharmacy)- taking 2 or more: risk 15%
• If take phenytion, valproate AND carbamazepine,
risk to fetus is up to 50%
• Benzodiazepines are not teratogenic
• Mechanism of teratogenesis though to be folate
deficiency
– All women should be on high dose folate (5mg/day)
preconceptually and throughout pregnancy
Management in Pregnancy
• Preconceptually:
• take folic acid 5mg/day from at least 12 weeks prior to conception
• Pregnancy
• Continue folic acid throughout as risks folic deficiency anaemia
• Continue current drugs if well controlled except
• Wean off/change phenobarbitone due to risks of neonatal
withdrawal convulsions
• Detailed fetal scan at 18-20 weeks with detailed fetal cardiac scan
at 22 weeks
• Advise shallow bath or shower (risks of drowning if fit)
• Relatives advised re: recovery position of seizures
• If give steroids, ↑dose if enzyme inducing drugs (phenytoin,
phenobarbitone, carbamazepine)
• Vit K 10-20mg orally from 34-36 weeks if on enzyme inducers due
to risks of fetal Vit K deficiency and Haemorrhagic Disease
Newborn
“I get tired more easily; my feet are swollen”
• A 35-year-old black woman is evaluated for progressive dyspnea 3 weeks
after delivery of her first child. Other than hypertension during pregnancy,
the pregnancy and delivery were uncomplicated. She has no history of
cardiovascular disease.
• On physical examination, the blood pressure is 110/70 mm Hg in both
upper extremities, the heart rate is 105/min and regular, and the
respiratory rate is 28/min. The estimated central venous pressure is 10 cm
H2O and there are no carotid bruits. The apical impulse is displaced and
diffuse. There is a grade 2/6 holosystolic murmur noted at the apex. Third
and fourth heart sounds are also noted at the apex. There is dullness to
percussion at the posterior lung bases bilaterally, and there are crackles
extending up half of the lung fields. Lower extremity pulses are normal and
without delay, but pedal edema is present.
• The electrocardiogram demonstrates sinus tachycardia. There are no STsegment or T-wave changes. The chest radiograph demonstrates bilateral
pleural effusions and interstitial infiltrates. The aortic contour is
unremarkable.
Diagnosis?
Which of the following is the most likely cause of
the patient’s current symptoms?
A. Acute myocardial infarction
B. Aortic dissection
C. Coarctation of the aorta
D. Acute pulmonary embolism
E. Peripartum cardiomyopathy
Peripartum cardiomyopathy
• Defined as heart failure with LVEF < 45%;
– diagnosed from 3 months before upto 6 months PP in the absence of an
identifiable cause.
• Usually diagnosed in month 1 postpartum.
• Typical features : time of onset, evidence of LV dilation (displaced and
diffuse apical impulse), and typical signs of heart failure.
• Risk factors :Age (>30 years at the time of the pregnancy), race (black,
African, Haitian), and the presence of gestational hypertension.
• Maternal mortality rate ~10%, peripartum cardiomyopathy is the major
cause of pregnancy-related death in North America.
• Urgent confirmation of global ventricular systolic dysfunction by TTE; and
treatment with standard heart failure therapy are critical.
• Improvement in LV function in ~ 50% of women within 6 months after
delivery. Intravenous immune globulin and pentoxifylline have been shown
to improve outcomes in some studies.
• Anticoagulation is recommended for thromboembolic prophylaxis when
LVEF < 35%.
Key physiologic changes: cardiovascular
• Hemodynamic changes
– Blood volume/cardiac output increase
• 50% increase, with half of this by 8 weeks
• Maximum blood volume expansion at 28 weeks
• Labor may increase cardiac output another 50%
– 10-20% increase in HR
– 25% decrease in systemic vascular resistance
• Systolic BP decreases by 5-10mmHg, diastolic by 1015mmHg
Key physiologic changes: cardiovascular
• Oncotic changes:
– Increased plasma volume by 50%
– Increased red cell mass by 33%
– Resulting dilutional anemia
Predictors of poor outcome in women with
heart disease
• New York Heart Association Class III or IV
– Symptoms with less than ordinary physical activity
or at rest
• History of prior cardiac event or arrhythmia
• Left sided obstruction in mitral or aortic valve
• Ejection fraction less than 40%
Siu, SC, Circulation 2001
“I feel dizzy ”
A 26-year-old woman who is 25 weeks pregnant is evaluated
in the emergency department for palpitations and episodic
lightheadedness. She has no history of cardiovascular
disease or tachycardia.
• On physical examination, her blood pressure is 100/70 mm
Hg and her pulse is 175/min. The estimated central venous
pressure is normal and there are no carotid bruits. The
apical impulse is not displaced. There are no murmurs or
abnormal heart sounds detected. The examination is
otherwise unremarkable.
• A Valsalva maneuver is performed by the patient and
carotid sinus massage is performed by the attending
physician, but the tachycardia continues.
Her Electrocardiogram
How would you treat?
Which of the following is the most appropriate
intravenous medication to administer at this
time?
A. Adenosine
B. Amiodarone
C. Digoxin
D. Diltiazem
E. Metoprolol
Pre-Pregnancy with Mechanical Mitral
Valve
• A 29-year-old woman with a mechanical mitral valve
prosthesis presents for pregnancy counseling. She has a
history of mitral regurgitation and had mitral valve
replacement for progressive left ventricular enlargement
several years ago. She recently married and would like to
start a family. She is asymptomatic and has been on a
stable dose of warfarin (4 mg/d) for the past 2 years.
• On physical examination, her blood pressure is 120/70 mm
Hg. The estimated central venous pressure is 3 cm H2O.
There is a crisp, mechanical S1. No murmurs are detected.
The remainder of the examination is unremarkable.
• Which of the following is the most appropriate
anticoagulation regimen for this patient if she becomes
pregnant?
Answer?
A.
B.
C.
D.
Continue warfarin, adjusted to INR
Stop warfarin; start aspirin and clopidogrel
Stop warfarin; start fondaparinux
Stop warfarin; start weight-based lowmolecular-weight heparin
E. Stop warfarin; Start Dabigatran
A Conundrum: Anticoagulation for
mechanical prosthetic valves in pregnancy
• Warfarin has a LMW: crosses placenta to cause poor fetal
outcomes especially in 1st trimester (embryopathy; still birth,
ICH, spontaneous abortion)
• Warfarin also has the lowest risk for maternal complications
and death
– Used in other countries outside the USA
• Fondaparinux approved for DVT/PE but not for
anticoagulation for mechanical valves
• LMWH is the choice here. Weight-based dosing is not
adequate.
– Monitor anti Xa activity levels weekly or biweekly to guide
dosing
Stout KK; Heart 2007; 93 (5):552-558
Prescribing in pregnancy
• Do not start any medication unless clearly
indicated
• Do not discontinue medicines that
successfully maintain the maternal condition
unless there are clear indications to do so
• Ask about and document non-prescription
meds
Lee R, 2000
Prescribing in pregnancy
• Have a pregnancy medication reference available
• Favor older medicines with longer record of use
• Check blood levels and consider increased and/or
more frequent dosing
– Increased volume of distribution, hepatic and renal
clearance
– Increased production of binding proteins—free drug
levels are better
Powrie, R SGIM 2000
Prescribing in pregnancy
• Educate and negotiate with your patient
– Pregnant women more likely to stop needed meds
• Report adverse outcomes
• Always consider the effect of not treating
• Remember that few drugs are absolutely
contraindicated
FDA Drug Ratings in Pregnancy
Category
A
Interpretation
B
Controlled human studies show
no risk
No evidence of risk in studies
C
Risk cannot be ruled out
D
Positive evidence of risk
X
Contraindicated in pregnancy
Limits of the FDA classification
• Hard to remember
• May be misleading
– Up to 60% of category X drugs have no human
data
– No information on degree of risk
– A drug may end up in category X simply if it has no
utility in pregnancy
– Rarely updated
– Efforts underway to address these concerns
Sciali, 2004 accessed from
www.reprotox.org
Drugs to avoid in pregnancy
•
•
•
•
•
•
•
ACE inhibitors: renal dysgenesis
Tetracycline: abnormalities of bone and teeth
Fluoroquinolones: abnl cartilage development
Systemic retinoids: CNS, craniofacial, CV defects
Warfarin: skeletal and CNS defects
Valproic acid: neural tube defects
NSAIDS: bleeding, premature closure of the ductus
arteriosis
• Live vaccines (MMR, oral polio, varicella, yellow
fever): may cross placenta
Lee, R 2000
Good References for Drug Prescribing
• Briggs, Freeman, and Yaffe: Drugs in Pregnancy and
Lactation, 2005.
• Lee, Rosene-Montella, Barbour, Garner, Keely:
Medical Care of the Pregnant Patient, 2000.
• www.reprotox.org
• www.motherisk.org
• www.micromedix.com (reprorisk)
• www.otispregnancy.org (free)
• Hale, T: Medications and Mother’s Milk, 2004. Also
www.ibreastfeeding.com
Example from Reprotox
• Agent Summary—Citalopram (Celexa)
Quick take: Based on experimental animal studies and
limited human reports, standard therapeutic use of
citalopram is not expected to increase the risk of
congenital anomalies. Use of serotonin reuptake
inhibitors late in pregnancy can be associated with a mild
transient neonatal syndrome of central nervous system,
motor, respiratory, and gastrointestinal signs. In a small
number of cases, the use of other serotonin reuptake
inhibitors after 20 weeks gestation has been associated
with an increased risk of neonatal pulmonary
hypertension.
Reprotox website 2006
Case #2
• 39 yo G4P2 for new primary care appointment
• Obese
• History of pulmonary embolus in prior
pregnancy
• Upreg positive today, 9 weeks by LMP
• Complaining of mild shortness of breath, O2
sat is 93%
Case #2
• What are some changes in the respiratory and
hematologic systems in pregnancy?
• How might they affect this patient?
• What would you do next?
Key physiologic changes: pulmonary
• Increased minute ventilation
– Mediated by progesterone
– Increased tidal volume>>respiratory rate
– Compensated respiratory alkalosis
– Normal ABG in pregnancy: 7.43/29/100
• PaCO2 of 40mmHg is very abnormal in pregnancy
• Fetus relies on high maternal PaO2
Key physiologic changes: pulmonary
• Greater tendency to pulmonary edema
– Increased cardiac output
– Decreased oncotic pressure
– Leaky capillaries
– Aggressive IV fluids
– Meds
Key physiologic changes in pregnancy:
Hematologic
• Hematologic/Immunologic:
– Procoagulant factors increase: factor VIII, vWF,
fibrinogen
– Protein S levels markedly reduced
– Increased risk of venous clots
• Greatest risk in post-partum period
Key physiologic changes: endocrine
• Endocrine:
– Insulin resistance, dyslipidemia
– Relative TSH suppression in first trimester
– Other thyroid changes
Key physiologic changes: renal
• Increased glomerular filtration rate
– Baseline proteinuria increases
– Drugs metabolized more rapidly by kidney
• Creatinine falls
• Collecting system dilates
Case #2
• You want to order a chest x-ray for initial
evaluation
• She is concerned about the effects on the
fetus
• What would you say?
Principles of diagnostic imaging
• Greater risk of harm by not getting a needed
study than getting one
• Little evidence that radiation exposures <5
rads have significant fetal effects
• Almost all imaging studies involve radiation
well below this level
– CXR <0.001 rad
– Chest CT PE protocol 0.001-0.002 rads
– CT abdomen/pelvis 0.64 rads
IV contrast
• Theoretical concern for effects on fetal thyroid
• Case reports of women receiving high dose
iodine in pregnancy-->no adverse outcomes
• General advice: avoid if possible, but use
contrast when clinically necessary
MRI
• Few studies
– Animal evidence shows little risk
• NIH consensus statement
– Recommends MRI be reserved for 2nd and 3rd
trimester if possible, but can be performed in
pregnancy
• Gadolinium
– Little data—use if clinically warranted
Case #2
• CT with PE protocol done: PE
• Managed with treatment dose low molecular
weight heparin, converted to subcutaneous
unfractionated heparin at 36 weeks
• Vaginal delivery of healthy baby boy
A patient with intractable itching
• A 23-year-old woman gravida 2 para 1 at 35 weeks with a singleton
gestation is referred from a dermatologist for intractable itching. The
itching is primarily on the palms of her hands and soles of her feet. It is
present day and night, and keeps her from sleeping. The patient also had
itching during her first pregnancy in which the fetus died in utero in the
third trimester. She states no explanation was given for the fetal demise
and the pregnancy was otherwise uncomplicated. Autopsy and karyotype
of the fetus were normal. She has no known prior history of liver disease
or risk factors for viral hepatitis. Her physical examination is notable for
numerous skin excoriations related to scratching and a gravid uterus. She
has no abdominal pain and a nonpalpable liver or spleen.
• Laboratory evaluation is notable for elevations of serum
aminotransferases, alkaline phosphatase, and total bilirubin (ALT 1201
IU/L, AST 910 IU/L total bilirubin 3.1 mg/dL alkaline phosphatase 400
IU/L). The GGTP is normal, but total serum bile acid concentrations are 10
times normal. Viral hepatitis serologies are negative. A right upper
quadrant ultrasound is normal
Diagnosis?
A.
B.
C.
D.
E.
Acute viral hepatitis
Choledocholithiasis
Primary biliary cirrhosis
Cholangitis
Intrahepatic cholestasis of pregnancy
Additional Information
• This patient's clinical presentation is consistent with intrahepatic cholestasis of
pregnancy (ICP).
– Serologic testing excluded viral hepatitis
– the high level of aminotransferases with normal GGTP makes primary biliary cirrhosis
unlikely.
– The absence of abdominal pain, fever, or biliary duct dilation helped exclude
choledocholithiasis and cholangitis.
– The patient's prior history of itching during pregnancy is helpful, since intrahepatic
cholestasis of pregnancy tends to recur.
– Intrauterine demise during her prior pregnancy may reflect the adverse fetal outcomes
associated with this condition and should prompt her clinician to advise increased fetal
monitoring with consideration of early delivery.
– ursodeoxycholic acid increases bile flow and has been used to relieve pruritus and
improve liver biochemical tests in patients with ICP. no adverse effects in the mothers
or babies
– In a pooled analysis that compared UDCA with all controls, patients who received UDCA
were more likely to report an improvement in pruritus (61 versus 27 percent;) and were
more likely to have total resolution of pruritus (42 versus 6 percent). Patients who
received UDCA were also more likely to have improvements in their transaminase and
serum bile acid concentrations and had a lower premature delivery rate (16 versus 34
percent; OR 0.44).
Gurung V, Middleton P, Milan SJ, et al. Interventions for treating cholestasis in pregnancy. Cochrane Database Syst Rev 2013; 6:CD000493.
A patient with elevated
aminotransferases
• A 26-year-old woman gravida 3 para 2 currently in her 14th week with a
singleton gestation is hospitalized with intractable nausea, vomiting, and
dehydration. During her two prior pregnancies, she also had severe
nausea and vomiting, which resolved early in the second trimester. Her
past medical history is otherwise unremarkable. She has not traveled in
the past year, and does not take any medications (including over-thecounter agents and herbal compounds) other than prenatal vitamins and
folate. Her physical examination is notable for dry mucus membranes, and
a gravid uterus. She has no abdominal pain, and does not have a palpable
liver or spleen.
• Her initial laboratory examination reveals elevations in serum
aminotransferases ALT (175 IU/L), AST (122 IU/L), serum total bilirubin (2.1
mg/dL). Amylase and lipase are normal. The albumin is slightly decreased
from normal values, but consistent with pregnancy. Liver biochemical tests
prior to pregnancy are not available. A right upper quadrant ultrasound is
normal. Urinalysis shows elevated ketones.
Diagnosis?
A.
B.
C.
D.
viral hepatitis
Autoimmune hepatitis
Drug toxicity
Hyperemesis gravidarum
Additional testing
• Serology for hepatitis A, B, and C is negative,
• antinuclear antibodies are absent
• serum protein electrophoresis is normal (making
autoimmune hepatitis unlikely).
• TSH is normal.
• Obstetrical ultrasound examination demonstrates a
normal singleton gestation.
• She was treated with antiemetics, IV fluids
• At 20 weeks of gestation, her symptoms completely
abate, and her liver biochemical tests return to normal.
A patient with elevated
aminotransferases and hypertension
• A 23-year-old woman gravida 1 para 0 currently with twin gestation
at 30 weeks is hospitalized with hypertension, for which
methyldopa had been prescribed at 28 weeks of gestation. Despite
treatment, she continues to be mildly hypertensive and is
developing a progressive rise in serum aminotransferases, which
are over 85 IU/L. Hepatitis serology and markers for autoimmune
hepatitis are negative. Her platelet count, peripheral blood smear,
and right upper quadrant ultrasound are normal. Urinalysis is
normal except for 1+ proteinuria.
• Within 36 hours, the patient develops progressive
thrombocytopenia, worsening hypertension, and a headache; and
her serum aminotransferase concentrations continue to rise
Diagnosis?
A.
B.
C.
D.
E.
Toxicity due to methyldopa
Early acute fatty liver of pregnancy
Severe preeclampsia
Autoimmune hepatitis
Hyperemesis gravidarum
A patient with nausea and vomiting in
the third trimester
• A 32 year-old woman gravida 1 para 0 with a
singleton gestation at 34 weeks of gestation is
admitted to the hospital with a three-day history
of nausea and vomiting, malaise, and jaundice.
Her blood pressure is mildly elevated. Urinalysis
shows trace protein, serum aminotransferases
range between 200 to 500 IU/L, serum glucose is
in the low-normal range. White blood cell count
and prothrombin time are elevated. She denies
any recent travel. Hepatitis serologies were sent,
but are unavailable
Diagnosis?
A.
B.
C.
D.
E.
Acute fatty liver of pregnancy.
HELLP syndrome
Atypical preeclampsia
Viral hepatitis
Intrahepatic cholestasis of pregnancy
How Common are these problems?
• Pregnant women with abnormal liver tests
represent 3 percent of deliveries*
– The majority of cases were attributed to
pregnancy-specific disorders ( preeclampsia,
HELLP syndrome, obstetric cholestasis,
hyperemesis gravidarum, acute fatty liver of
pregnancy);
• the reminder were attributed to other conditions (eg,
sepsis, drug-related, bile duct stones, hepatitis) or of
uncertain etiology
*Ch'ng CL. Et al; Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut 2002; 51:876.
Evaluation of Liver Disease in Pregnancy
History and ROS
Hx of Pruritus during previous pregnancies or while on OCPs, abdominal pain,
nausea or vomiting, polyuria and polydypsia, drugs, travel, exposure to viral hepatitis,
history of gallstones. Note trimester of pregancy
Physical Examination
Temperature, bloodpressure, proteinuria, liver examination
Blood tests
CBC including platelets; Routine LFTs including PT; serum creatinine, electrolytes,
glucose and uric acid levels
Serology for viral hepatitis (A,B,C) and CMV. Test for Hepatitis E if suspected
Measure total serum bile acids if cholestasis suspected
Urinalysis and Culture
Ultrasound of the liver and bile ducts
Monitor evolution of symptoms and LFTs before and After delivery
Questions?